Sequencing Therapy in ITP: Current Guidelines


Considerations when referring to the ASH 2019 guidelines and International Consensus Report for recommendations regarding treatment sequencing to manage immune thrombocytopenia.

Bhavesh Shah, RPh, BCOP: As you mentioned, Ali, the ASH [American Society of Hematology Clinical Practice] Guidelines, which we waited a decade for, came out about a year and a half ago. Comparing those guidelines with the International Consensus Report, what are your thoughts in regard to these 2 guidelines for ITP [immune thrombocytopenia]?

Ali McBride, PharmD, MS, BCOP, FASHP, FAzPA: David, do you want to go first since you brought it up earlier?

David Hughes, PharmD, BCOP: With these guidelines, there’s a lot of guidance for, as Ali mentioned, using steroids or IVIg [intravenous immunoglobulin] in the up-front setting. We use them; that’s our recommendation. Then, as Ali started to mention, there’s not a set panel that says if you fail X, you go to Y. Many of us in the oncology or hematology space like seeing treatment in a sequenced action, where if you fail here in first-line therapy, you go here in the metastatic setting. Well, in ITP, we don’t have that. It’s basically picking and choosing, weighing the patient characteristics, which both guidelines call out and say we should specify treatment to patient characteristics. This is where a lot of the individualization comes in from a patient-to-patient perspective that we talked a little about earlier. Can the patient come for therapy? Is there a preference for oral vs IV [intravenous] vs subcutaneous? What does the monitoring look like? Are there food restrictions? Are there ethnicity restrictions or changes that alter which therapy you may use? A lot of these are considerations discussed within these 2 guidelines. But there’s not a true guidance on using 1 therapy plus or minus another when that occurs.

Bhavesh Shah, RPh, BCOP: In oncology, we’re so structured: This is first-line therapy; this is what you use for second line; this is what you use for third line. With ITP you basically choose what is the best for the patient and their needs. The evidence supports that, because you’re not going to have head-to-head comparison of these agents. Now, we have 3 or 4 TPO [thrombopoietin] receptor agonists. We’ll think about what agent should be used of those TPO receptor agonists, and can I go from 1 TPO receptor agonist to another? It’s amazing how dysfunctional treatment is for ITP. Even the guidelines don’t provide much guidance. Some of the evidence has been lagging, especially with SYK inhibitors. But now SYK inhibitors or TPO receptor agonists are recommended for second-line therapy. That’s the major change that we’ve seen in our practice.

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